Healthcare-associated infection:

management and control of MRSA

causative agent

Kuntaman
Department of Medical Microbiology,
Faculty of Medicine Airlangga University /
RSUD Dr.Soetomo Surabaya

Seminar PPRA, Yogyakarta, 15-16 Juli 2017 1

Learning objectives

1. The antimicrobial resistance (AMR)

and the development of AMR
2. Multi-drug Resistant Organism
3. Management of Nosocomial Infected
Patients: MRSA

2
 The development of
Antimicrobial Resistance
(AMR)

3
 Overuse
In mild infection

Misuse
Less supporting
Facility
A.B. Abuse AMR

Underuse
Less funding
WHO Global Strategy for containment of
antimicrobial Resietance. 2001 4
 - Too higher dose
Overuse
In mild infection - Too long regiment

Misuse - No evidence based empiric thx

Less supporting
Facility - No support data for defin. thx

Underuse - Self A.B. Usage

Less funding
- Under dose
5
 Overuse of
3rd GEN CEPH
(in Hospital)

ESBL Producing bacteria:

- MDR
- Res 3rd Gen Cepha
- Co-res Cipro
6
 AMR mechanisms?

Mutation
Natural
Biologic Gene exchange
Proses Selection
Transmission

7
 Gene exchange

Conjugation
8
Transduction
Selection

9
10
Multi-drug Resistant Organism
(MDRO)

MDRO
XDR: Res to almost all
PDR: Res to all available antibiotic
11
 MDRO
Res against 3 or more Classes of AB
Mostly in Comm and Saphro MO
Prevalent in hospital. WHY

12
Development
of MDRO
Selection of New
A.B. In which
Cumulative
the Res to old
1 Selection
A.B. Still
present

Plasmid ONE Plasmid

2 Mediated carry more
than 2 Res
gene
13
Development
of MDRO

Emerging Over Use AB

1 AMR

2 Spread AMR UP/SP

14
 Multiple Selection
Selection rate: 1 / 10^6-8
Drug-1 (Cefotaxim)
Drug-2 (Amikacin)
Drug-3 (Ciprofloxacine)

Multiple Res
15
 Lab Diagnosis
Standard
Based on CLSI (Indonesia)

16
 What is the Sensitive means
Factors:
Antibiotic concentration in blood
stream can reach the certain level
Antibiotic can kill the microorganism
in the blood stream/tissue
Antibiotic is relatively NO harm to
the host

Resistance: Fail to kill the m.o. 17

 MRSA TESTING
Methicillin Resistance Staphy aureus

RESISTANCE :
- Group Penicillin
PEN, AMP, AMX
- Group Cephalosporin
CEPH-1, CEPH-2,CEPH-3, CEPH-4
- Group Carbapenem
MEM, DOR, IMI
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Rule for Reading: Staphylococcus spp

Result
Interpretation
P, OX/Fox
S, - Sen: Group Penicillin, Cephem,
Carba
R, S Res: B-lact Labile Penicillin/PEN
Sen: B-Lact Stable Penicillin/Clox
Kombinasi B-Lact Inhibitor
Cephems, Carbapenem
R, R Res: all Beta-lactam
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B-lactamase Labile B-Lactamase Stable
Penicillin Penicillins
Penicillins (Penicillin) Cloxacillin, Dicloxacillin,
Aminopenicillins Methicillin, Nafcillin,
(Amp,Amox) Oxacillin
Carboxypenicillin
(Ticar, Carbenicillin)
Ureidopenicillin (Pipera)

CLSI, 2012
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Patient have an Infection: ??
SIRS: SOFA:
Temp BP
Leu Brain
RR Lactate
HR
Sumber Inf:
Pneumonia
ISK
BSI etc
21
MRSA

22
 Problem
Pasien dgn Infeksi MRSA: ?? AB:
Clinda
Pasien Kolonisasi: ?? VAN
GEN
RIF
LNZ
SXT
TET
Levo
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Hospital AB Policy RSUDDS
VAN: Hanya untuk MRSA
Restriksi:
Golongan Carbapenem (
MEM, IMI, DOR)
VAN
PTZ
TGC
LNZ
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 Pasien Inf dgn MRSA
Infeksi: ?? [SIRS, Sumber Inf]
Ya MRSA: VAN atau lain
Tidak Non MRSA: AB lain
Tidak Infeksi: no AB

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 Kolonisasi MRSA
Cleaning:
Mupirocin
AB: RIF/SXT/ERY/CLIN 5-6 hari
Mandi dgn CHG, seminggu
Cek ulang MRSA: neg ??

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 SP

Hand Washing or Hand Rub

Isolasi

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 RINGKASAN

1. MDRO: MDR, XDR, PDR

2. Lab Diagnosis?
3. Lab Diagn: MRSA
4. Management
Infeksi: ?
AB: ?
Restriksi AB

28
 RINGKASAN

1. MRSA: Infeksi
Diagnosis Infeksi
MRSA: ??
VAN hanya untuk MRSA
2. Kolonisasi: Cleaning
Mupirocin
AB 5 hari
Mandi dgn sabun CHG
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East Java Health Office 2015

Thank you for your attention 30